Peripheral Nerve InjuryOpen Access Research article Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type Ricardo Monreal* Address: "Manuel Fajardo" Teac
Trang 1Peripheral Nerve Injury
Open Access
Research article
Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type
Ricardo Monreal*
Address: "Manuel Fajardo" Teaching Hospital Orthopedics and Traumatology Department Zapata y calle D, Vedado, CP: 10400, Havana, Cuba Email: Ricardo Monreal* - rjmg@infomed.sld.cu
* Corresponding author
Abstract
Background: Loss of elbow flexion due to traumatic palsy of the brachial plexus represents a major
functional handicap
Then, the first goal in the treatment of the flail arm is to restore the elbow flexion by primary direct nerve
surgery or secondary reconstructive surgery
There are various methods to restore elbow flexion which are well documented in the medical literature
but the most known and used is Steindler flexorplasty
This review is intended to detail the author's experience with Steindler flexorplasty to restore elbow
flexion in patients with brachial plexus palsy C5-C6-C7 where wrist extensors are paralyzed or weakened
Methods: We conducted a retrospective follow-up study of 12 patients with absent or extremely weak
elbow flexion (motor grade 2 or less), wrist/finger extensor and triceps palsy associated; who had
undergone surgical reconstruction of the flail upper limb by tendon transfer (Steindler flexorplasty) and
wrist arthrodesis to restore elbow flexion The aetiology of elbow weakness was in all patients brachial
plexus palsy (C5-C6-C7 deficit) Data were collected from medical records and from the information
obtained during follow-up visits
Age, sex, preoperative strength (rated on a 0 to 5 scale for the flexors of the elbow, wrist flexors, pronator
and triceps), previous surgery, length of follow-up, other associated operative procedures, results and
complications were recorded
Results: The results are the follows: Eleven patients were found to have very good or good function of
the transferred muscles One patient had mild active flexion of the elbow despite the reconstructive
procedure
There were no major intraoperative complications Two patients experienced transient, intermittent
nocturnal ulnar paresthesias postoperatively In both patients these symptoms subsided without further
surgery
Conclusion: Our study suggests that in patients with C5-C6-C7 palsy where the wrist and finger
extensors are paralyzed or weaked, the flexor-pronators muscles of the forearm are strong but the triceps
is not available for transfer; Steindler flexorplasty to restore elbow flexion should be complemented with
wrist arthrodesis
Published: 11 July 2007
Journal of Brachial Plexus and Peripheral Nerve Injury 2007, 2:15
doi:10.1186/1749-7221-2-15
Received: 25 April 2007 Accepted: 11 July 2007
This article is available from: http://www.JBPPNI.com/content/2/1/15
© 2007 Monreal; licensee BioMed Central Ltd
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Trang 2Traction injury of the brachial plexus results in partial or
total paralysis of the upper limb, especially when there is
paralysis of elbow flexion Good hand function is wasted
if the hand cannot be maintained in a useful position
Loss of elbow flexion due to traumatic palsy of the
bra-chial plexus represents a major functional handicap
Then, the first goal in the treatment of the flail arm is to
restore elbow flexion by primary direct nerve surgery or
secondary reconstructive surgery
There are various methods to restore elbow flexion which
are well documented in the medical literature One of the
earliest procedures for restoring function to the elbow,
Steindler flexorplasty first reported in 1918 [1], is still
pre-ferred by many surgeons
This review is intended to detail the author's experience
with Steindler flexorplasty to restore elbow flexion in
patients with brachial plexus palsy C5-C6-C7 where wrist
extensors, fingers extensors and triceps are paralyzed or
weakened
Methods
We conducted a retrospective follow-up study of 12
patients with absent or extremely weak elbow flexion
(motor grade 2 or less), wrist/finger extensor and triceps
palsy associated; who had undergone surgical
reconstruc-tion of the flail upper limb by tendon transfer (Steindler
flexorplasty) and wrist arthrodesis to restore elbow
flex-ion The aetiology of elbow weakness was in all patients
brachial plexus palsy (C5-C6-C7 deficit) Data were
col-lected from medical records and from the information
obtained during follow-up visits
Five of the patients in this series had been previously
treated by surgical exploration with neurolysis, nerve
grafting or nerve transposition At the time of tendon or
muscle transfer no patient was considered a candidate for
additional nerve exploration or grafting
The wrist was fused in a position that will not be fatiguing
and that will allow maximum grasping strength in the
hand This is usually one of 10° to 20° extension, the long
axis of the second or third metacarpal shaft being aligned
with the long axis of the radial shaft (Figure 1)
When a solid wrist fusion is obtained (usually about 12
weeks) a tendon transfer (Steindler flexorplasty) is
man-datory Two points must be emphasized with regard to
this procedure: (1) Powerful activity of the
flexor-prona-tor forearm muscles and (2) proximal transfer (4–5 cm)
and fixation of a piece of the medial epicondyle (less than
one centimetre in thickness) with its attached origin of the flexor-pronator muscle group in the middle of the ante-rior aspect of the humerus (Figure 2)
Age, sex, preoperative strength (rated on a 0 to 5 scale for the flexors of the elbow, wrist flexors, pronator, flexor dig-itorum superficiales and triceps), previous surgery, length
of follow-up, other associated operative procedures, results and complications were recorded (Table 1) Flexion was measured with a goniometer from the posi-tion of complete extension so that 0° of flexion equalled completed extension In the examination of patients with shoulder fusion or trapezius transfer, care was taken to prevent the patient from using the shoulder to change position of the elbow
Wrist arthrodesis performed with the single-intramedullary-rod technique
Figure 1
Wrist arthrodesis performed with the single-intramedullary-rod technique
Trang 3Functional improvement was scored using the criteria
established by Alnot and Abols [2] Two aspects must be
kept in mind to evaluate the results obtained after
Stein-dler flexorplasty: muscular power and range of motion
Very good: Active elbow flexion against resistance (Grade
4) and range of flexion 120°
Good: Active elbow flexion against resistance (Grade 4)
and range of flexion below 120°
Mild: Active elbow flexion against gravity but not resist-ance (Grade 3) and range of flexion 80° or more
Fail: No active elbow flexion against gravity (Grade 0 to 2)
Additional operative procedures were performed to enhance function of the extremity These included two shoulder arthrodesis and four trapezius transfers to treat flail shoulder (Table 1)
Results
The average duration of clinical follow-up was 27.8 months, with a range from 4 months to 62 months There were two female and 10 male patients with an average age
at operation of 27.2 years (range 21 to 52 years)
Preoperatively, all patients had powerful activity of the flexor-pronator forearm muscles, two patients had active elbow extension grade 3 and 10 patients had no detecta-ble active extension of the elbow (grade 2 or less) The patients' assessments of the outcome showed that 11 patients were found to have very good (Figure 3) or good function of the transferred muscles and one patient had mild active flexion of the elbow despite the reconstructive procedure (Table 1)
There were no major intraoperative complications Two patients experienced transient, intermittent nocturnal ulnar paresthesias postoperatively In both patients these symptoms subsided without further surgery There were
Table 1: Data on the flexorplasties evaluated.
Case Age and Sex Pre operative Strength* Length of Follow-up (months) Previous Surgery Associated
Procedures Results Complications
Elbow flexors Wrist flexors FDS Pro Triceps
* Strength rated on a scale of 0 to 5
nl: neurolysis; ng: nerve grafting; nt: neurotisation
VG: very good; G: good; M: mild; F: fair
TT: Trapezius Transfer
SA: ShoulderArthrodesis
UP: Ulnar Paresthesias
FDS: Flexor digitorum superficiales
Pro: Pronators
Steindler flexorplasty: proximal transfer (4 – 5 cm) and
fixa-tion of a piece of the medial epicondyle with its attached
ori-anterior aspect of the humerus
Figure 2
Steindler flexorplasty: proximal transfer (4 – 5 cm) and
fixa-tion of a piece of the medial epicondyle with its attached
ori-gin of the flexor-pronator muscle group in the middle of the
anterior aspect of the humerus
Trang 4no wound infections or and no losses of fixation of the
transfer
Discussion
Many patients with brachial plexus injuries can be
bene-fited by neurolysis nerve grafting and neurotization
proce-dures Loss of elbow flexion after traumatic brachial palsy
represents a major functional handicap Although a direct
approach to the neurological lesion has given some
encouraging results, these can be incomplete and for this
reason tendon transfers still have an important role The
use of muscle transfer depends on the individual patient
but should always be part of an integrated program that
includes nerve repair and muscle transfers
Restoration of active elbow flexion is the chief concern in
the patient with upper or total brachial plexus paralysis
Restoration of active elbow flexion should be considered
in most cases as a higher priority than shoulder function
There are various methods to restore elbow flexion which
are well documented in the medical literature These
reconstructive procedures include proximal transfer of the
forearm flexor-pronator or wrist extensor mass [1-4]
ante-rior transfer of the triceps tendon [5-7] pectoralis major
transfer [8-10] latissimus dorsi transfer [11-13] transfer of
the flexor carpiulnaris [14] transfer of the
sternocleido-mastoid with or without shoulder arthrodesis [15] and
free muscle transfer [16]
Anterior transfer of the triceps tendon was designed for patients in whom paralysis or injury had left the flexor-pronator mass unusable for transfer
Transfer of the pectoralis major muscle to the biceps ten-don requires a grade of at least 4 of 5 for the strength of the sternal head of the pectoralis major muscle
Transfer of the latissimus dorsi muscle also requires a grade of 4 of 5 for the strength of the donor muscle and is technically demanding but results in moderate elbow flex-ion superior to that seen with other techniques
A free microneurovascular muscle transfer may be per-formed in a limited number of patients The most com-monly selected donor muscle is the gracilis This procedure is indicated when no functional muscles are available for transfer
The type of muscle transfer depends on the muscle groups remaining available Alnot [17] recommended triceps transfer in cases of triceps-biceps co-contractions, and Steindler's procedure when the elbow flexors reach only grade 2, contrarily it is contraindicated when the elbow flexors are classified as grade 0, when the wrist flexors are weak, or when wrist and finger extensors are paralyzed Sometimes it is recommended to complete Steindler flex-orplasty by a pectoralis minor transfer in some C5-C6-C7 palsies
In general proximal advancement of the forearm flexor/ pronator muscle group should be considered as the initial treatment in all patients because of its simplicity and lack
of donor deficit According to Segal, Seddon, and Brooks [18], when the pattern of paralysis is such that a free choice of procedures is possible, the Steindler flexorplasty
is preferable Carroll [6] advises against transferring a muscle arising from the medial epicondyle to restore hand function until after any indicated flexorplasty has been done and the strength and function of the trans-ferred muscles have been regained A modified Steindler flexorplasty was used by Chen W [19] to restore elbow flexion in 8 patients with post-traumatic flail elbow and the results were not compromised in patients whose flexor tendons had been transferred for wrist and finger exten-sion
Brunelli GA et al [20] recommend a modified Steindler procedure to restore elbow flexion The modifications were designed to avoid the phenomenon of the patient having to make a fist in order to obtain elbow flexion (Steindler's effect) According with the authors, Steindler flexorplasty is indicated in upper plexus lesions (C5-C6); other transfers are more appropriate for lower plexus pal-sies
Case 7, after flexorplasty of the right elbow and arthrodesis
on the right shoulder
Figure 3
Case 7, after flexorplasty of the right elbow and arthrodesis
on the right shoulder Active elbow flexion to 135 degrees
(Very good result) allows positioning of the hand to the head
and face for independent self-care
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There is general agreement regarding the efficacy of the
Steindler flexorplasty Despite varying criteria, a number
of authors [1-4] have reported a 70 to 90 per cent success
rate with this procedure We agree that it is the procedure
of choice for a patient who has paralysis of the biceps
bra-chii and brachialis, a functional hand, and sufficient
fore-arm flexor power to warrant transfer
Proximal transfer of the medial epicondylar muscles is an
important adjunct in the rehabilitation of the paralyzed
upper extremity, when there is adequate power of this
muscle mass and full extension of the elbow is not
required for transfer or ambulation When the medial
epi-condylar muscles are weak or full extension of the elbow
is essential for transfer or ambulation, an alternative
pro-cedure must be considered
An isolated lesion of C7 does not cause a complete
mus-cular paralysis because the proximal muscles innervated
by C7 are also innervated by C6 (pronator teres, teres
major, flexor carpi radialis, triceps, extensor indicis and
digiti minimi proprii) while the lower muscles innervated
by C7 are also innervated by C8 (palmaris longus, triceps,
extensor carpi ulnaris, abductor pollicis longus, extensor
pollicis brevis, extensor pollicis longus, flexor carpi
ulnaris) The sensory function is only very slightly
involved if C7 is involved in isolation because of the
over-lapping of C6 and C8 However, if one contiguous spinal
nerve or trunk is involved, the muscular paralysis
becomes evident [21]
Increase in elbow flexion strength comes at the expense of
increased passive moments for wrist flexion and forearm
pronation caused by the increased excursions of these
muscles imposed by the transfer The only way to
counter-act the tendency for passive muscle forces to flex the wrist
is with active wrist extension [22]
The treatment of choice depends of the injury In C5-C6
palsies with no elbow flexor function (grade 0–2);
Stein-dler flexorplasty and triceps transfers have always
pro-vided good results In C5-C6-C7 injuries, with no elbow
flexor activity (grade 0), the triceps can be used if it
receives a dominant innervation from C8-T1 but when the
elbow flexors are grade 2, the Steindler flexorplasty is
usu-ally sufficient with active wrist extension or fused wrist
Our study suggests that in patients with C5-C6-C7 palsy
where the wrist and finger extensors are paralyzed or
weaked, the flexor-pronators muscles of the forearm are
strong but the triceps is not available for transfer; Steindler
flexorplasty to restore elbow flexion should be
comple-mented with wrist arthrodesis
References
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